Concern has been raised over the psychological trauma some medical
students appear to experience when undertaking human dissection. While
previous research has been undertaken overseas, the present study sought
to further investigate this phenomenon within a New Zealand university.
Questionnaires were administered to 100 students attending the Auckland
School of Medicine both immediately prior to their first dissection
experience and at intervals over the following two years. A small but
significant proportion (10%) exhibited a stress reaction one week
following the first dissection, with the percentages dropping to 6.3 at
one month, 3.6 at 8 months, 2.1 at one year, and zero at 2 years.
Multivariate regression analysis associated preexisting psychological
morbidity and stress related to the impending dissection with post
dissection trauma. Coping behaviours were used relatively infrequently
and associations with gender, ethnicity and baseline psychological
variables identified. These results suggest that the initial stress
associated with human dissection dissipates relatively rapidly, but such
a finding should not be used to undermine efforts to identify and
support the relatively few students who may initially be distressed by
the experience.

**********

Dissection of the human body is employed as a method of instruction
in anatomy courses at both the Auckland and Otago medical schools in New
Zealand. Although a time-honoured and almost universally accepted
educational process, over the last 10-15 years attention has been drawn
to the traumatic effects of dissection on some students and the
implications of such trauma on subsequent education and practice
(Charlton, Dovey, Jones, & Blunt, 1994; Gustavson, 1988; Hafferty,
1988). Aspects of dissection that medical students are reported to find
distressing include revulsion at the sight and smell of the cadavers,
shock at confronting death, desecration and dismemberment, violation of
cultural taboos, dehumanisation, and invasion of privacy (Hafferty,
1988; Jones, 2000). The process is said to confront students with their
fears and anxieties regarding life, death and human mortality that
require time to resolve (Gustavson, 1988).

Investigations into such 'dissection trauma' have
produced varying results, with reported proportions of students
exhibiting distress ranging from 5 to 25 percent (Jones, 2000). Some
authors found symptoms of severe depression, anxiety, insomnia and
intrusive visual imagery that appear to resemble the symptoms of
post-traumatic stress disorder (Gustavson, 1988). In an Auckland-based
study of physiotherapy and occupational therapy students exposed to
cadavers and prosections, Hancock, Williams and Taylor (1998) reported
that 9% exhibited an initial post-traumatic stress reaction, but this
proportion subsequently dropped to 2.1% on re-testing 18 months later.
Many students reported that dissection was their first direct encounter
with dead bodies, and that for some it was the first time they had seen
'a naked old person, let alone a naked old and dead person'.
The researchers commented that to cut into the human body, to dismember
it, to mutilate, and disassemble it, was outside the realm of everyday
experience, and one that normally would constitute an extreme violation
of societal norms.

In the present study the researchers adopted the concept of stress
as being the substantial imbalance between demands that are made and the
ability of individuals and groups to respond with the support available
(Taylor, 2002a). Since its inception the concept had been defined both
as the strain imposed upon an object or person and as the consequence of
tension (Taylor, 2002b), but in line with recent empirical and
theoretical developments (cf. Zeidner & Endler, 1996), the
interactional model just described is preferred. Consistent with that
model, when designing the present project the authors considered a
cluster of aetiological factors concerning individuals, their histories
and immediate circumstances that McFarlane and Yehuda (1996) presented.
Additionally they took into account the coping strategies adopted by
medical students were also taken into account, because to some extent
those related to active coping and problem solving are known to buffer
psychological symptoms, while those related to avoidant coping and
denial, such as intellectual detachment, might serve as an adaptive
short-term response, but were they to persist, they would be maladaptive
and make the clinicians less empathetic in their dealings with patients
and their families (Hafferty, 1988; Charlton et al., 1994; Nnodim,
1996).

While overseas studies into the effects of dissection on medical
students may have some relevance to New Zealand, differences in student
populations suggest the need for a New Zealand-based study. For example,
Auckland has a unique ethnic mix of Maori, Pacific and Asian students in
the medical school, and unlike their counterparts in North America, they
are not required to have an undergraduate degree prior to their entry.

The purpose of the present study therefore was to investigate the
psychological impact of dissection and the coping strategies employed by
medical students attending the Auckland School of Medicine. In
accordance with the model of stress described above, and the
authors' previous findings for physiotherapy and occupational
therapy students (Hancock et al., 1998), it was expected that medical
students would also show elevated levels of psychological stress.
Further, given the more intense involvement of medical students with the
process of dissection, it was anticipated that they would show greater
levels of stress than the previously mentioned allied health students.

Method

Participants

In 1998, 110 students at the University of Auckland School of
Medicine were introduced to gross anatomy in the second semester of
their first year, and they continued the subject over the following
three semesters. With the approval of the Ethics Committee of the
University of Auckland, all students were invited to partake in this
study by giving their written consent. Those who either did not sign a
written consent form, or failed to complete an initial post cadaver
exposure stress assessment questionnaire, were subsequently excluded.
The anonymity of participants was respected.

Of the 110 students in the course, 100 (90.9%) fulfilled the
conditions of participation. Fifty-one were male and the mean age of the
group was 18.8 years. Ninety-one percent were between the ages of 17 and
19 years. Forty-four (44%) described themselves as Pakeha/ European, six
(6%) as Maori, twelve (12%) as Pacific Island or part Pacific Island and
twenty-two (22%) as Asian, with the remaining 16 students of assorted
ethnicity (Indian, Sri Lankan and Middle Eastern). The majority of
students came from urban backgrounds (88%) with twelve (12%) from rural
environments. Fifty-nine had previously seen a dead person, and ten of
them indicated that they had been "very" or
"extremely" traumatised by the event. As expected, the
educational standard of the students was high; 95% had achieved a New
Zealand "A" Bursary or University Entrance Scholarship during
their final secondary school year.

Psychometric measures

The study utilised four psychometrically robust and brief clinical
self-report questionnaires that gave reliable indications of key factors
in psychological adjustment, different combinations of which had been
used successfully with emergency service workers who had been involved
in body-recovery after disasters (Alexander & Wells, 1991), and with
occupational and physiotherapy students involved with dissection and
witnessing prosection during the course of their studies (Hancock et
al., 1998). The first, the GHQ-20 (Siegert, McCormick, Taylor, &
Walkey, 1987), was a 20 item adaptation of Goldberg's (1978)
four-factor General Health Questionnaire (GHQ) for psychological
disorder. The instrument investigates general illness, sleep
disturbance, anxiety and dysphoria, and severe depression, without
implications of chronicity. In common with other screening
questionnaires the GHQ does not make a clinical diagnosis. It
"focuses on breaks in normal function, rather than lifelong traits
... (and) ... concerns itself with two major classes of phenomena:
inability to continue to carry out one's normal 'healthy'
functions, and the appearance of new phenomena of a distressing
nature." (p5 Goldberg & Williams, 1988). Respondents rate
themselves on a four-point severity scale, according to how they have
recently experienced each GHQ item: better than usual, same as usual,
worse than usual, or much worse than usual. A total score is computed by
adding the scores of each item. The GHQ binomial scoring method was
employed with scores of 0-0-1-1 for the four response options, resulting
in a minimum score of 0 and maximum of 20. The conventional cutoff point
of 4 was employed as an indicator of psychological morbidity. (Goldberg
& Williams, 1988).

The second assessment instrument, the 45 item Stress Arousal
Checklist (SACL) (Mackay, Cox, Burrows, & Lazzerini, 1978), touched
on certain cognitive and emotional reactions, specifically related to
the impending dissection, that comprised the two factors of stress and
arousal. Adjectives associated with the stress sub-scale of this
instrument include "tense", "peaceful",
"apprehensive" and "calm". Those on the arousal
sub-scale include "vigour", "drowsy",
"activated" and "lively". An ordered four point
response scale ranges from "definitely feel" through
"definitely do not feel". Items were given a score of one
where respondents felt the adjective definitely or slightly described
their feelings, and zero where they were either undecided or the
adjective did not describe their feelings. Nineteen of the stress
related items contributed to the stress subscale score which could range
from 0 to 19, and 15 contributed to the arousal subscale (range from 0
to 15).

The Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez,
1979), the third instrument, was employed to assess the psychological
impact of dissection on the students. The IES measures subjective stress
related to a specific event and comprises items composed of commonly
reported experiences following a potentially traumatic event. Each of
the 15 items has four response options, viz., "not at all".
"rarely", "sometimes" and "often". Each of
these options were scored 0, 1, 3 and 5 respectively. The questionnaire
provides an overall scale, sub-scales of intrusion and avoidance, and
can be used repetitively. It has good reliability and validity
(Alexander & Wells, 1991). Horowitz (1982) described subscale scores
of 0-8 as a minor reaction, 9-19 a moderate reaction, and a score of 20
or above a clinically important reaction, and McFarlane (1988) employed
a cut-off score of 30 on the IES as indicating a traumatic stress
reaction. The IES was administered on five separate occasions over a two
year period to assess changes in the stress response.

The fourth scale, the COPE questionnaire (Carver, Scheier, &
Weitraub, 1989) was administered 12 months after the students'
first dissection to assess the dissection-related coping strategies that
the students might have used. The COPE is a 60-item multidimensional
coping inventory that is reported to be a reliable, relatively stable
measure with convergent and discriminant validity, although Lyne &
Roger (2000) have strong reservations about the ambitious claims that
have been made for its use. The COPE provides 15 scales, two of which
(Restraint coping and Drug/ Alcohol use) were not employed in this study
because the questions were considered either non-applicable (Restraint
coping) or ethically questionable (Drug/Alcohol use). Each COPE scale
comprises four items and respondents indicate on a 4-point scale how
often they employ each coping strategy. Response options are: "I
usually don't do this at all"; "I usually do this a
little bit"; "I usually do this a medium amount"; "I
usually do this a lot". Thus, for each of the 13 COPE scales
respondents could score a minimum of 4 and maximum of 16.

Finally, provision was made on all questionnaires for students to
make any additional comments they might feel prompted to express,
because the set items might overlook significant reactions, and also the
subjective expression of such reactions often adds welcome richness and
relevance on which the researchers might reflect. As Bracken (2002) is
at pains to point out, on epistemological grounds the conventional
scientific methods for observing traumatic reactions often fall short by
neglecting existential reactions.

Although all of the participating students completed the
demographic and background information questionnaire, for reasons that
are unknown slightly fewer completed the psychometric instruments. The
internal consistency of the GHQ in this study was 0.85 (Cronbach's
alpha), with corresponding values for the SACL stress and arousal
sub-scales of 0.88 and 0.87 respectively. The percentages of students
responding to the repeated administrations of the IES were: IES1W
(100%), IES1M (95%), IES8M (84%), IES1Y (84%) and IES2Y (60%). The
initial (IES1W) yielded an alpha reliability coefficient of 0.87 for the
overall scale, and coefficients of 0.86 and 0.79 for the intrusion and
avoidance sub-scales. Seventy nine percent of students completed the
COPE at one year. In general, the internal consistency of the 13 scales
was acceptably high, with alpha coefficients ranging from 0.59 to 0.89.

Procedures

Ethical and legal obligations, and the pedagogic practice of
placating anxiety, precluded the adoption of an experimentally
'pure' research design that would have had the intake of
students allocated randomly into groups in which one would have been
excluded from prior consideration and the other supported. Consequently
immediately prior to their first sight of a cadaver, students were given
a one-hour preparatory session on the spiritual aspects of death and
dying, followed by a standard one-hour orientation to the dissection
laboratory in which the obligatory procedural issues concerning the
donor program and the storage and preservation of cadavers were
explained, and it was emphasised that the donated bodies, there to
facilitate learning, were to be treated with respect. They were also
briefed on the standard of behaviour and conduct required of them in the
dissection room.

The psychometric testing took place at predetermined intervals over
a period of two years, beginning two weeks prior to the students'
attendance at the dissection room with base-line GHQ and SACL stress and
arousal levels specifically related to the impending dissection, and
gathering demographic and background data. Then the students experienced
two successive dissection laboratory sessions in which, over a period of
six hours, they either witnessed or assisted in dissection. The IES was
administered one week following the first dissection experience (IES1W)
to detect the initial response, and it was repeated on four subsequent
occasions, i.e. at one month (IES1M), eight months (IES8M), one year
(IES1Y) and two years (IES2Y) to detect any subsequent fluctuations of
response. After one year the COPE was administered to elicit patterns of
coping.

Statistical methods

The statistical package SPSS for MS Windows (10.0) was used for
data analysis, with results being considered significant at the usual 5
per cent level or below. The internal consistency of psychometric
measures was assessed by Cronbach's alpha. Differences between
groups at any one time, and changes over time, were assessed by analysis
of variance (ANOVA) and repeated measures ANOVA. Because the primary
outcome (IES) scores were not normally distributed, a square-root
transformation was employed so that the data better met the assumptions
of the parametric tests. Finally, multiple regression procedures were
used to identify variables independently predictive of outcomes.

Results

The mean score of the GHQ-20 was 14.9 (SD 7.5). These baseline
results showed that 35 of the 76 students (46%) had above threshold
GHQ-20 scores. The SACL stress and arousal scales had mean scores of 8.2
(SD 5.1) and 8.6 (SD 4.2) respectively. On this measure 90% of students
indicated some degree of emotional stress on 15 of the 19 items
assessing stress associated with the impending dissection. In descending
order, the percentages of stress-related adjectives checked by the
students were 'apprehension' (65%), 'uneasy' (52%),
'worried' (38%), 'fearful' (29%) and
'distressed' (26%).

The mean values for the overall IES1W scale and its intrusion and
the avoidance sub-scales were 12.9 (SD 11.7), 6.4 (SD 6.8) and 6.5 (SD
6.8) respectively. The intrusion items with the highest mean scores were
'pictures about it popped into my mind' and 'thought
about it when I didn't mean to'. The corresponding avoidance
items were 'I avoided getting myself upset when I thought about it
or was reminded of it' and 'my feelings about it were kind of
numb'. Ten percent of students exceeded McFarlane's (1988)
cut-off score ([greater than or equal to] 30) for the total IES scale,
thereby exhibiting a stress reaction. Percentages of students exhibiting
stress reactions to subscales of the IES1W are shown in Table 1.

The dotplots, means and SDs for successive administrations of the
IES (but excluding IES8M) are shown in Figure 1. The dots in the Figure
depict Total IES scores for each individual who completed the
assessment, and the relationship of the scores to McFarlane's
cut-off value indicative of a traumatic stress reaction. The mean score
for IES1W was significantly higher than for each follow-up
administration (p<0.01), and reductions between the means of
successive tests were significant (p<0.05) with the exception of that
between IES8M and IES1Y (p = 0.182). These reductions in mean IES values
were reflected in the progressive reduction in the percentages of
students exhibiting stress reactions at each assessment point, i.e. 6.3
at IES1M, 3.6 at IES8M, 2.1 at IES1Y and 0 at IES2Y.

The results also showed that none of the ten initially stressed
students exhibited significant stress at the one or two year
assessments. However, while eight of these students completed the IES1Y,
only three of them completed the IES2Y. One student who had not exceeded
the stress threshold at one week did exhibit a stress reaction at one
year.

Similar marked reductions were observed in the scores for the
successive administrations of the IES sub-scales. Thus, at baseline
(IES1W), 5% of students demonstrated stress responses on the Intrusion
subscale and 7% for the Avoidance sub-scale. Corresponding figures for
the later IES measures were: 3.2% and 4.2% at IES1M and 0% for both
subscales at IES8M, IES1Y and IES2Y.

Table 2 presents mean initial scores for the Total IES 1W and its
sub-scales analysed in relation to demographic, background, GHQ-20 and
SACL variables. For convenience of analysis scores for the stress and
arousal scales of the SACL were divided into tertiles. Analysis of
variance tests showed that:

(1) Female students had significantly higher initial Total IES and
Avoidance mean values than males.

(2) In contrast to students who had not previously seen dead
bodies, or those who had, but not been traumatised by the event,
students who had been markedly traumatised by such an experience
exhibited significantly higher mean IES intrusion scores.

(3) Students who gained a University Entrance Scholarship exhibited
significantly lower mean IES Intrusion scores than those with an A or B
bursary only.

(4) Students with GHQ-20 scores exceeding the distress cut-point
had significantly higher Total and Intrusion IES scores than those
falling below the cut-point.

(5) All three SACL groups differed significantly in terms of their
scores on the Total IES and the Avoidance subscale. Tukey post-hoc
comparisons revealed that students with the highest scores on the SACL
had significantly higher mean Total (p=0.020) and Avoidance (p=0.019)
IES scores than those with intermediary scores on the SACL.

The independent variables depicted in Table 2 were entered as dummy
variables into three separate multiple regression models predicting
Total IES, Intrusion and Avoidance scores. These models enabled
assessment of the unique contribution of each independent variable when
controlling for the effects of all the others. GHQ-20 caseness (i.e.
scores [greater than or equal to] 4 indicating psychological morbidity)
and the stress related to the impending dissection (SACL) remained
significantly (p < 0.05) associated with scores on the Total IES1W.
The independent variables explained 34% of the variance in the IES1W
scores, leaving 66% of the variance unexplained. Lower school academic
achievement and GHQ-20 caseness were significantly (p < 0.05)
associated with higher Intrusion and Avoidance scores respectively.

In addition to the above analyses, more parsimonious explanations
of the data were sought by submitting the independent variables in Table
2 to stepwise multiple regression procedures. Variables reaching
significance (p < 0.05) in these analyses were consistent with the
previous models except that, in addition, stress related to the
impending dissection (SACL) was also significantly associated with both
IES Intrusion and Avoidance scores.

With regard to the COPE, the mean values for each of the scales are
shown in Table 3 along with the percentages of students scoring greater
than or equal to twelve. Such values indicate students were, on average,
employing the coping behaviours underlying each scale a "medium
amount" to "a lot". The most frequently employed coping
strategies were Positive reinterpretation and growth, Humour and
Acceptance. Least used coping behaviours were Behavioural disengagement,
Denial, Focus on and venting of emotion and Suppression of competing
activities.

The COPE scores also showed that females had significantly higher
mean scores than males (p < 0.05) for Active coping (5.8 vs 4.8) and
Seeking support for emotional reasons (6.3 vs 5.0), while males had
significantly higher mean scores for Humour (7.1 vs 8.9). Relative to
each of the other ethnic groups, Pacific Island students showed a
significantly higher mean score for Turning to religion. Students
exhibiting symptoms of minor mental disorder (GHQ-20 cases) exhibited
significantly (p < 0.05) higher mean scores for Seeking emotional
support, Venting emotions, Denial, Mental disengagement and Humour. Our
highest scale means (8.0-8.2) indicated that, on average, students were
employing the relevant coping behaviours infrequently ("a little
bit"). Further, the coping behaviours underlying only three scales
(Humour, Acceptance and Turning to religion) were employed by more than
10% of the students to any significant degree ("medium amount"
to "a lot").

Total IES scores one week post dissection showed significant but
low to moderate ([r.sub.s] = 0.22 to 0.42) positive correlations with
ten of the thirteen COPE scales. Students exceeding McFarlane's
(1988) stress reaction cutoff score on the IES showed significantly
higher use of Acceptance (p<0.05) as a method of coping.

Discussion

Using McFarlane's (1988) criterion, 10 per cent of our medical
students displayed initial if transient Total IES reactions of
post-traumatic stress, with 5% and 7% exhibiting clinically important
reactions for the respective Intrusion and Avoidance scales, and only
one student exhibiting significant stress reactions after 12 months, and
none after 24 months. These reductions in percentages of students
exhibiting symptoms of stress were paralleled by marked reductions in
Total IES mean values over time (see Figure 1). In comparison with the
values reported in other studies, the Total IES1W means of 10.4 for
males and 15.5 for females in the present investigation are slightly
higher than the respective mean scores of 6.9 and 12.7 that Horowitz et
al. (1979) found in their study of medical students exposed to cadavers.
But the values were similar to those obtained in our previous study of
physiotherapy and occupational therapy students, i.e. 12.6 for males and
15.7 for females (Hancock et al., 1998). However, the Total IES1W mean
score of 12.9 for the whole group in the present study was considerably
lower than that reported for more severe psychological trauma--such as
the mean value of 29.7 for patients with advanced cancer (Kassa et al.,
1993) and of 28.5 for Swedish survivors of the car ferry m/s Estonia.
(Eriksson & Lundin, 1996).

As the students progressed through the course their comments tended
to reflect a perceptual change that paralleled the reduction in stress.
Initially, some comments indicated marked distress:

"I didn't really like the whole experience. The first
time we went in I cried and have since felt like crying about it too. I
find it difficult each time we go into the lab and it takes a while
before 1 can participate in dissection. It is improving each time
though."

At later stages comments reflected adjustment to the experience and
tended to be more reflective and less reactive.

"I think of it as a very unreal experience. It's amazing
how you come to think of it as something purely academic. It
doesn't always click that it "s actually something that would
make a normal person feel awkward or scared."

"I haven "t found it affected me all that much--you just
pretend it's not actually a person if it "s getting
difficult." Perhaps as to be expected from university students many
of their written comments illustrated the process of
intellectualisation.

"It sounds rather mean but the way I dealt with it was to
treat the cadaver as a learning tool rather than a dead body."

Some students also expressed concern that they might have adapted
too easily to the cadaver experience and they were critical of
themselves for having done so.

"It actually bothers me that I have become as desensitised to
the whole thing. I was very upset about it but I'm not anymore.
This very abnormal thing has become normal and I find that quite
disturbing in myself."

A number of factors were identified as predictive of stress
following initial exposure to the dissection laboratories. In the
bivariate analyses (Table 2), the finding that female students had
higher Total IES1W and avoidance mean values than males is consistent
with other research (Hancock et al., 1998; Horowitz et al., 1979). The
higher Total IESIW scores for those who had been traumatised by a
previous death suggests that past traumatic memories may have increased
the students' emotional sensitivity to death. While all students in
this cohort were high academic achievers, students with the higher
school qualification (University Entrance Scholarship) exhibited
significantly lower mean Total IES1W intrusion scores. This may indicate
that these students were better able to focus on the intellectual
aspects of the task and correspondingly avoid, suppress or cope with
negative emotional responses, and put the dissection experience into an
appropriate philosophical context.

The proportion (46%) of students exceeding the cut-off score on the
GHQ appears to be high, but other researchers have also reported high
rates of psychological disorder using this measure, and have expressed
concern at the stress associated with medical education (Benitez,
Quintero & Torres, 2001; Guthrie et al., 1995; Aktekin et al., 2001)

In our previous study of physiotherapy and occupational therapy
students (Hancock et al., 1998) we found that psychological distress as
measured by the Hopkins Symptom Checklist ( Green, Walkey, McCormick
& Taylor, 1988) was positively correlated with scores on the Total
IES and each of its sub-scales. In the present study we employed the
GHQ-20 to assess psychological morbidity, and found that students
exceeding the cut-off had significantly higher mean Total IES1W scores
for the overall scale and intrusion sub-scale. A similar trend was
observed for the avoidance sub-scale but the results fell just short of
significance (p = 0.055).

Higher mean Total IES and Avoidance scores were also observed for
students exhibiting high pre-exposure stress scores as measured by the
SACL. Taken together, the GHQ-020 and SACL findings lend support to our
expectation that students experiencing psychological strain are at
increased risk of becoming stressed by the additional demands imposed by
dissection. However, the finding that students with the lowest level of
pre-exposure anxiety had higher IES1W scores than those with moderate
levels of apprehension was unexpected. This may indicate that those
students who exhibited least anxiety had given little thought to the
impending dissection, and therefore were unprepared for the experience.

Our mean COPE scale scores are low compared to values reported in
several studies by Carver et al. (1989) In one study undergraduate
students were required to complete the COPE when considering their most
stressful event of the past two months. In a second study undergraduates
completed the COPE by indicating how they generally responded when under
"a lot" of stress. These investigations employed 12 of the
COPE scales used in the present study. Mean values for our study are
consistently lower for each of the scales with our means less than half
Carver et al.'s for five of the 12 scales.

The finding in our study that males used more humour in coping than
did females, is consistent with studies reported by Hafferty (1988),
William (1992), and Phelps and Jarvis (1994), and together with their
significantly less frequent use of Seeking support for emotional
reasons, it suggests they conformed to the stereotype and were more
reluctant than females to discuss their feelings. In contrast, Home
Tiller, Eizenberg, Tashevka, and Biddle (1990) found that Australian
medical students did not use humour and suggested its absence was
related to the high proportion of non Anglo-Saxons in the class:
however, we failed to find a significant relationship between humour and
ethnicity. But in a somewhat related study of police officers involved
in body handling after a disaster, Alexander and Wells (1991) reported
that nearly all respondents found humour helpful, and McGarvey, Farrell,
Conroy, Kandiah, and Monkhouse (2001) found that 45% of students at the
Royal College of Surgeons in Ireland used humour as a means of coping
with their course work.

Regarding the influence of cultural factors on coping responses,
Pacific Island students used Turning to religion as a means of coping
significantly more than other ethnic groups. This finding reflects the
integral and important place of religion in Pacific Island culture that
Lealaiauloto and Bridgman (1997, p10) described as "a system of
powerful spiritual beliefs, both Christian and traditional which ...
underpin the Pacific views of the world', and Taylor (in press)
found to be important in the recovery of Pacific Islanders_from
stressful experience.

The evidence showed that preexisting psychological distress
(GHQ-20) and that resulting from exposure to dissection (IES1W) were
associated with higher COPE scores. It appears that students thus
affected, when faced with the stress of dissection and unable to remove
it from their academic lives, more frequently resorted to coping
strategies to reduce their emotional turmoil and focus on the task at
hand.

As noted earlier, it has been suggested that certain coping
behaviours adopted by medical students (e.g. detachment) might have
adverse consequences for their future roles as clinicians. Charlton,
Dovey, Jones, and Blunt (1994) went so far as to contend that students
employing such distancing strategies would develop a less caring
attitude. Other researchers described similar defense mechanisms, viz,
"objectification," "distancing" (Lella &
Pawluch, 1988) and "rationalization" (Nnodim, 1996:
Abu-Hijelh, Hamdi, Moqattash, Harris & Heseltine, 1997). Such
behaviours are thought to help students to focus on the task at hand, to
keep their emotions in check, and to view a potentially negative
experience in a positive manner: they appear to be measured by a number
of the COPE scale, including Positive reinterpretation and growth,
Acceptance and Suppression of competing activities. However, while these
coping behaviours were among the most frequently employed by our
students, less than one fifth reported using them to any notable degree.

While this study provides useful information relating to the manner
in which students coped with dissection it has a limitation that
deserves mention. The COPE questionnaire was administered after the
students had completed one year of their gross anatomy course. Such an
interval may not have allowed accurate recall of early coping
behaviours. Future studies might therefore usefully assess coping
strategies closer to the initial dissection. Repeated administration of
the measure might then be employed to assess changes in coping
strategies over time.

Finally, although positive student perceptions of the value of the
dissection experience were not addressed specifically in the present
study, many students made spontaneous comments that attested to the
positive value of the learning experience, such as:

"This type of learning is an effective, maybe the most
effective way to learn, feel and memorise anatomy. Personally it drives
me to take my study seriously and to learn as much as I can about the
human body. It gives a human face to what I am studying. At the end of
the day I will be treating a human being who has a face and feelings and
deserves the best of the service of knowledge in my medical training.
"

In conclusion, this investigation of psychological trauma
associated with the process of dissection of human cadavers, the
predictors of such trauma, and the behaviours employed to cope with the
experience, shows that a relatively small but significant percentage of
medical students had initial adverse affects. While the indications are
that the initial stress associated with human dissection dissipates
relatively rapidly, the finding should neither be used to trivialise the
reactions nor to neglect those students who might initially be
traumatised. Educators need to take care to identify and support the few
individual students who might be temporarily disturbed by the
potentially traumatic experience.

Given that every medical student in New Zealand is exposed to
cadaver dissection, further research is warranted to address limitations
of the present study. While coping strategies appeared to be
infrequently employed by our students, research is required to more
adequately investigate the effect of coping strategies on the initial
trauma response and to track changes in coping over time.

Benitez, C, Quintero J & Torres R. (2001). Prevalence of risk
for mental disorders among undergraduate medical students at the Medical
School of the Catholic University of Chile. Revista medica de Chile [Rev
Med Chil], 129, 173-178.

Green, D., Walkey, F., McCormick, I., & Taylor, A. (1988).
Development and evaluation of a 21-item version of the Hopkins symptom
checklist with New Zealand and United States respondents. Australian
Journal of Psychology, 40, 61-70.

Gustavson, N. (1988). The effect of human dissection on first-year
students and implications for the doctor-patient relationship. Journal
of Medical Education, 63, 62-64.